Note on using this video

Delivering sad news is a very difficult experience for staff and for family members/loved ones. One of the hardest jobs we have is delivering the news to those who were closest to the patient. If it is at all possible, it is far better to deliver this news in person. However, there are occasions where it is necessary to tell somebody about a death by telephone. This might be the case if the person closest to the patient is far away, or if they have communicated that they want to be informed straight away of any changes. Clearly, it is optimal if there have already been ‘warning shots’ in prior face-to-face conversations with the person closest to the patient, and you may or may not have been involved in what has been said to them already.

Communicating by phone adds complexity to an already difficult conversation. First, you will have fewer clues as to the person’s reactions and emotional state. Second, if the person reacts to the news very badly, you will not be able to provide direct support. This situation is especially difficult if the person is alone when you call them. It is important to (1) keep the person on the phone as you listen to them and provide what comfort you can, and (2) strongly urge them to find support nearby (a neighbour, a friend, and so on) – can you persuade them to commit to contacting someone as soon as your call has ended? You can also offer to make this call yourself for them. Strongly discourage the person from driving alone to the hospital, care home or healthcare facility. Finally, recognise that this kind of conversation is also very taxing to you, consider if you would benefit from some support or a little time to yourself after the call. The background details to this case study may not map precisely onto your experiences and work situation. To get the most from this video, focus on the communication skills used, rather than on the precise factual details of the case.

Supporting materials

Visit our webpage for supporting materials on good listening skills.

Click this link to download the Debrief in PDF format

Background

Mrs Noor Mansouri lived with her son Anil. She was admitted to the Healthcare of Older People Ward via the Emergency Department with a chest infection and following several hours lying on the floor following a fall in the bathroom whilst Anil was out at work.

Noor has been generally frail, she has a heart failure diagnosis, and has been living with Anil for the last six months as she was struggling with activities of daily living at home. On admission, she was oriented in time and place, but very uncomfortable. She needed help of one person to move in and out of bed, chair, and to use the toilet. Her son informed the staff that he, his Mum, and their GP had discussed cardio-pulmonary resuscitation, and that the GP had documented this via a DNAR order. This was confirmed and recorded in her hospital notes. In discussion with Noor and Anil, the medical team has written a Treatment Escalation Plan. She has a chest infection - not responding to IV antibiotics, her heart failure is worsening, and she has been increasingly breathless. Over the previous day, Noor became even more breathless, and occasionally disoriented. Anil has visited her for several hours each day since she was admitted and has a close relationship with her. Anil has emphasised to the nursing staff that he wants to be kept informed about his mother’s care and condition (whatever the time of day or night).

Situation

Senior staff nurse Mary Cunningham is the most senior member of nursing staff on the night shift. She has already met both Noor and Anil whilst on a day shift. One of the healthcare assistant staff has discovered Noor not breathing, with blue lips and no pulse, she appears to have been dead for at least a few minutes. The healthcare assistant immediately alerted Mary, who confirmed that Noor had died. Mary decides that she should inform Anil immediately as he has requested to be kept informed about his mother.

Clips

There are three clips in this scenario.

FIRST CLIP
INITIATING THE CONVERSATION
00:00 – 00:47

We see Mary preparing by placing a ‘Do Not Disturb’ sign on the door of the small office from which she will phone Anil. A clock on the wall shows that it is midnight.

Mary has the notes open on the desk, she double checks the names and phone numbers. She settles herself, and internally prepares for this sensitive conversation. She dials, and Anil, sitting in an armchair at his home, answers his phone. Mary apologises for phoning so late at night, Anil sounds anxious as he responds.

SECOND CLIP
SHARING INFORMATION
00:48 – 04:38

Anil asks if his Mum has got worse, Mary answers this honestly. The tone and content of her reply give Anil forewarning of what is to come, her tone and content also convey calmness, seriousness, and compassion. Mary confirms that his Mum has died. Anil responds with distress – crying and sobbing, Mary gives him time, and gently supports him with her words. When he is a little less distressed, Mary checks whether he is on his own. He is, Mary encourages him to seek the support of a neighbour he mentions. Next, Mary tells Anil about how his Mum had been prior to her death. Then she tells the story of her having been found to have died. Anil says he feels he should have been there. Mary tells him how common it is that a person dies when their loved one is not there, she also reiterates that his Mum looks peaceful. Anil becomes a little calmer, so Mary moves the conversation to when he will come to the hospital.

THIRD CLIP
CLOSING THE CONVERSATION
04:39 – 07:00

Mary explains the steps and support involved in getting to the ward. She prepares Anil for coming in – she mentions changing his Mum into clothing that she liked – he says he will bring an item in.

Mary tells Anil what he will see - including that curtains are closed, and that she has removed unneeded medical equipment. She reiterates that he should come with his neighbour driving and bring his Mum’s nightgown.

She doublechecks if he has questions, and they end with goodbyes.

Mary settles herself for a short time, she might go and find a colleague for a short debrief alongside a cup of tea.

Communication Skills

FIRST CLIP
INITIATING THE CONVERSATION
00:00 – 00:47

Mary double checks who she is speaking to, all of the preparation steps depicted are important in helping you conduct this difficult conversation as well as you can.
Very smoothly, and without sounding like she is just repeating by rote, Mary gives her name, her role (in a way that is specific to his Mum), and a reminder that they have met: “I’m Senior Staff Nurse on your Mum’s ward, I met you a couple of days ago.”. As you will know, staff are told to introduce themselves with: ‘Hello my name is… and my role is…’. Occasionally, this can result in introducing oneself in a way that comes over as rote, as not personal to the particular person and their circumstances. (Perhaps you have experienced this yourself). Notice that Mary avoids this in two ways. Firstly through her tone of voice – it is gently melodic – not robotic, and her tone is fitted to the sad, sensitive conversation to come. Secondly, she personalises her role with her “on your Mum’s ward”.
In terms of tone of voice, provided you are paying attention to ‘just this person at just this time’, your tone of voice will automatically reflect what you are paying attention to. You already have capacity to adjust your tone of voice to different people and circumstances – you’ve been doing it nearly all your life! So, be confident that you can use tone of voice to convey you are paying attention and that you recognise this is a sensitive situation and conversation.
In terms of personalising introducing yourself, when you state your role, add a phrase that personalises this. One way to personalise is to briefly add information on how you are connected to the person and the care team, ‘I’m one of the doctors in your oncologist’s team’. Mary personalises in this way by saying she works on Anil’s ward, and that Anil and she have already met. Another way to personalise your introduction is to not only state your role, but also briefly say what you are going to do, e.g. ‘I’m a radiographer here and I’m here to X-ray your chest.’
Notice that personalising does not necessarily take lots of time – it can be accomplished quickly and smoothly with just a few words.
After introducing herself, Mary apologises for phoning Anil so late at night. After saying hello, Anil asks “Is everything okay?”. Of course, anyone in Anil’s circumstance would deduce that if the nurse rings “so late at night”, everything is not okay with regards his Mum.
Moving away from the conversation in this video for a moment. As you probably know, sometimes in these conversations, the person you are talking to immediately asks you if their loved one has died. If they do so, then you should respond truthfully at that moment, something like ‘Yes, I’m so sorry to tell you that they died a few minutes ago’. The next stages of the conversation usually then involve the same things as in this scenario. These include emotional distress and your response to it, and your providing - where truthful – information that the bereaved person may find of comfort, for instance that the death was peaceful, that a member of nursing staff was with them, and so on.

SECOND CLIP
SHARING INFORMATION
00:48 – 04:38

Anil asks Mary two questions: “Is everything okay?”, and shortly after: “Has Mum got worse?”. He does not immediately ask if his mother has died, giving Mary a fair bit of space to move step-by-step towards the sad news itself. She says that she is “sorry to say” it’s not okay. And then before stating that his Mum has died, she says “I’m sorry to have to tell you….”.
In these conversations, where possible, it is skillful to take a step-by-step approach to the sensitive matter/the sad announcement. Through her ‘sorry’ phrasing, and her tone of voice - serious, sad, compassionate - she forecasts the coming news. In other words, Mary’s words and her tone of voice work as ‘warning shots’. In fact, if you are calling at a late hour at night, the phone ring or buzz is a warning shot in itself.
The step-by-step approach works by helping the person you are talking with to come to a gradual realisation of the news (and all that it means). Research shows that people find this approach helpful and gentle, and also that this gradual realisation makes it much less likely that the person on the receiving end will have an extreme reaction at the point where you state the sad news.
Mary listens attentively to Anil’s quietly voiced signs of his upset. Often, when distressed, people only let out quiet sobs, sighs and so on, pay acute attention to these because of course they are indicators of how distressed someone is feeling.
With a sobbing voice, Anil says “I’m so sorry” Mary responds “it’s okay” and “take your time Anil”.
People very often apologise amidst showing obvious signs of distress such as crying during an interaction. These apologies are to do with the fact that we are holding up the conversation, and that we aren’t available to participate in the conversation at this point. Gently accepting these apologies, as Mary does with “It’s okay”, is likely to be received as compassionate. In these situations of distress, you should not to try to ‘jolly things along’, nor convey that you yourself are uncomfortable (sighing, flicking a pen, tapping a foot and so on), and you should not attempt to press on to the next thing you need to cover in the conversation. Mary conveys the opposite of these with her calm: “Take your time Anil”.
Waiting, staying quiet, giving gentle reassurances, as Mary does here, all convey that you are accepting and acknowledging the person’s distress. In practice, this can be really difficult. For you the staff member, it can feel like it’s taking ages for the person to become more able to take part in the conversation again. Try to bide your time, whilst it can feel long, usually it’s quite short-lived. Further, if the person is in great distress, even if you try to force the conversation on, they won’t be able to participate, so it won’t be a conversation.
Conversations require the people involved to collaborate. If one of the people involved is unable (or unwilling) to collaborate, it is not possible to have or continue the conversation.
No matter how skilled you are as a communicator, you are absolutely reliant on collaboration from and with the other person within the conversation.
Anil continues to show some distress through sounds, words, breathing and crying. Mary leaves silences, with some words of reassurance and empathy. At one point, Anil says “I knew this could happen”. By saying very little, Mary gives opportunities for Anil to say more should he opt to do so. When he does so, his words give Mary more understanding of his perspective. What he says shows that his Mum’s death is not unexpected, that he had awareness it could happen at this time.
Mary now asks “Is somebody with you at the moment?”, Anil says he is on his own. Some guidance on this kind of phone call encourages you to ask this kind of question at the very start of the call. There is a disadvantage to doing so though. This being that asking this question at the very start will often be understood as indirectly, but very clearly stating their loved one is dead. This can then mean you can use the step-by-step approach to help the person come to a gentle, gradual realisation. This is why in our scenario and guidance, we encourage you to asking this ‘is someone with you’ question after you’ve given the sad news.
It transpires that Anil is on his own. Mary encourages him to find support by waking his neighbour. This can be especially important where there is a possibility the recently bereaved person might drive to where their loved one has died. Later in this conversation, Mary reiterates, strongly and clearly, that Anil should wake his neighbour and not drive.
“Anil, if it’s okay with you, I’m just going to talk you through your Mum’s evening before she died”. Her wording here implies asking permission in a gentle and informal way. In this kind of conversation and scenario, the family member doesn’t often straightforwardly ask about events before the death. But we know that people usually want this information, and also that (depending on circumstances) providing this information gives you an opportunity to provide comforting and reassuring information about the person and their care.
It is of course important that what you say is truthful. Where it is truthful, provide information likely to be found comforting, for instance, reassurances about the deceased person’s peacefulness, whether someone was with him, the care and support given to them.
Notice that, Mary comes to recounting the discovery of Anil’s Mum’s death in a context where Anil now knows about the peaceful run-up to this event. When we say things is very important to how they are received. As in the step-by-step approach discussed above, what we have said beforehand affects how people react to sensitive and difficult news and topics.
Mary gives the sad news once more “your Mum had died”. She uses the most direct form of reference to death here. This makes does not leave room for any ambiguity or ‘false hope’. In this scenario, the use of ‘died’ works well in terms of clarity.

However, research has found that staff, patients, and family members only rarely use the words died, dying, and death, and only in particular circumstances. There are good reasons not to always use the most direct term – often, it can be just too painful, blunt, harsh. Instead patients, family members, and healthcare staff use indirect terms. It is important to clarify that some indirect words and phrases are absolutely clear in their meanings, whereas some indirect words and phrases are not clear, and should not be used when talking about dying and death.
So, some are unequivocally hearable as meaning death or dying. In our language and culture “passed away” and “passed” are understood to specifically mean died, and not to mean anything else when used in context. On the other hand, “moved on” can be heard as died, but it could also mean moved to a different physical place, so this is indirect and ambiguous. ‘Had a cardiac arrest’ is another indirect but ambiguous phrase – some people will not know what it means, some people will know but may hold onto a hope that their loved one is still alive.
Besides certain terms, such as ‘passed away’, people often use another way of being indirect but unambiguous. This involves using ‘opposite phrases’, for instance: ‘did not survive’ (versus died); ‘is moving towards the end of his life” (versus moving towards his death, or, is dying).
Anil says he feels he should have been with his mother when she died. Research shows many bereaved people feel great regret and guilt about not having been in the room with the person when they died. With the aim of lessening guilt and regret, it is recommended that staff explain that it is a surprisingly common occurrence that the dying person will die when their loved one is not there. Some staff choose to say that it might be that the dying person somehow finds it easier to let go in those circumstances. At slow pace, Mary provides this information to Anil. She then moves on to repeat comforting information – that his Mum looked peaceful.
Mary moves to another matter which Anil is likely to find of comfort. She expresses appreciation and respect by remarking on how Anil had spent a lot of time with his Mother whilst she was in hospital, and that “I got a sense that you were very close”. With this phrasing, she avoids stating their closeness as a fact, instead she states her experience.
Mary now leads the conversation towards talking about what happens next. She spells three options out very clearly “you’re more than welcome to come in immediately, or you can wait for a couple of hours, or you can come in the morning”. She then mentions, almost as if in brackets, something important and related – that he should not drive. Whilst acting as a reminder, this also gives Anil a bit of time before he states which option he will take up. Anil opts to come in immediately.

THIRD CLIP
CLOSING THE CONVERSATION
04:39 – 07:00

Mary explains how security and parking will be arranged. She does so at a measured pace.
She reminds him about clothing for his Mum. She tells him she has removed medical equipment from around his Mum’s bedside. She mentions that other family members can come if they wish
She has limited the information she gives him to the immediate circumstances. She tells him that when he has come in, and when he is ready there will be a conversation about practicalities and what must be done next.
She summarises what he needs to do now. She double checks for whether he wishes to go over anything again at this point. He says no, and the conversation ends.
A couple of communication skills points are relevant to what Mary says: “Anil, will I go over any of that again, or is there anything you’d like to ask me?”.
Checking a person’s understanding and their retention of information is quite a tricky part of this kind of conversation for at least two reasons. First, people might not recognise what we have not followed or retained. Second, people (all of us!) don’t always feel comfortable admitting that we might have missed something.
There are alternatives that can be helpful. In particular, rather than asking “will I go over any of that again”, Mary might have opted to just to just go ahead and do so after giving a reason - something like: ‘I’ve covered a lot of ground, so I’ll just go over the key points again’.
Another communication skills point to make here is about the recommendation that we ask patients and family members questions like: ‘is there anything you would like to…?’ and ‘do you have any questions?’. Research has shown that avoiding the word ‘any’ can work better for encouraging someone to come up with points or questions. Alternatives include ‘some things’. This is because ‘any’ encourages a negative response. (Notice how we conventionally use ‘any’ for the negative: ‘I don’t have any pain’, but not for the positive: ‘I have pain’).

Conversations about normal dying (18.56 mins)

Giving sad news of a death on the phone (7.03 mins)

Conversations about post mortem examination (10.58 mins)